STRATEGIC CHOICE OF HEART VALVE PROSTHESIS DUNG VAN HUNG , MD.PhD HO CHI MINH HEART INSTITUTE BACKGROUND  1st mechanical valve replacement in 1960 ( Starr-Edwards)  1967  1969:  1980 : Ross procedure was introduced 1st aortic porcine valve was implanted : pericardial valve was created ( Carpentier-Edwards) 1990s : 1st generation of stentless tisue valve ( Prima, Freestyle & Toronto valve)  Early  2012 : # 20.000 valve in Japan, 90.000 valve in USA & 280.000-300.000 valve in the world were implanted  In Viet Nam ( 2015) # 800 valve CLASSIFICATION OF HEART VALVE PROSTHESIS Mechanical Valves : Caged-ball, Tilting disc, Bileaflet Tissue Valves : Bioprosthetic : Porcine ( heterograft) Pericardial Biological : Aortic homograft Pulmonary autograft Self-expandable : TAVI ( Core valve, Sapien 3) TAVI ( Lotus valve) Sutureless : Perceval ( Sorin) PROSTHETIC VALVE: INTERVENTION Recommendations COR LOE Choice of valve intervention and prosthetic valve type should be a shared decision process I C A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired I C IIa B A mechanical prosthesis is reasonable for AVR or MVR in patients 70 years of age Either a bioprosthetic or mechanical valve is reasonable in patients between 60 years of age and 70 years of age Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered in young patients when VKA anticoagulation is contraindicated or undesirable COR LOE IIa B IIa B IIb C THROMBOSIS, BLEEDING, STROKE, PANNUS Emergent treatment Very high mortality Linear risk STRUCTURED DEGENERATION Planned treatment Moderate mortality Late risk AVR: Choice of Prosthesis Patients’ age is probably the most important factor in recommending tissue or mechanical valve 2.Bioprosthetic valves are ideally suitable for older patients (>70 years) or those who are not likely to outlive the valve (comorbidities) Mechanical valves should be recommended to younger patients ( Mechanical situation : Tissue valve ANTI-COAGULANT & ANTI- PLATELET  Can ‘t take OAC or will not take OAC : Tissue valve  Can ‘t follow up closingly  Need : Tissue valve to minimize bleeding : Tissue valve  Special jobs  Lifestyle  Pregnancy : Tissue valve CO – MORBIDITY (CARDIAC & NON-CARDIAC)  Need to aortic or mitral valve replace associated with CABG : Bioprosthetic > Mechanical valve  History of haemorrhage ( stroke, severe GI tract bleeding, cancer…) : Bioprosthetic valve  Chronic renal failure needs to dialyse : the same (Bioprosthetic versus mechanical prostheses for valve replacement in end-stage renal disease patients: systematic review and meta- analysis Kevin Phan et al J Thorac Dis 2016;8(5):769-777 )  If life expectancy > 5y : Mechanical > Bioprosthetic valve (Contemporary perioperative results of heart valve replacement in dialysis patients: analysis of 1,616 patients from the Japan adult cardiovascular surgery database Tadeka K et al J Heart Val Dis 2013 Nov;22(6):850-8.) PERMANENT ADDRESS  Regular examinations and echocardiograms, anti-thrombotic therapy, and appropriate antibiotic prophylaxis against endocarditis  Nearly heart center or provincial hospital : Mechanical > Tissue valve  Far away heart center or cannot FU regularly : Tissue valve  Ethnics group : Tissue valve HEMODYNAMIC PERFORMANCE OF VALVE  New choice : new generation of heart valve prosthesis ( CE Magna Ease, SJM Trifecta, Solo Freedom, OnX, Regent, ATS-Medtronic, Slimline….)  For AVR : supra-annular valve is better INCOME + SOCIO-ECONOMIC STATUS + EDUCATIONAL BACKGROUND + COST AND AVAIBILITY OF PROSTHESIS + QUALITY AND AVAIBILITY OF MEDICAL SERVICES Algorithm for selecting a valve procedure Durable valve repair > 10y possible Yes No Physician assessment Patient ‘s preference Life expectancy < 15y Major co-morbidity 1.Accept risk of reoperation 2.No coagulation 3.Minimal life style change Tissue valve Life expectancy 15-30 y No co-morbidity Life expectancy >30 y No co-morbidity Minimize reoperation 2.Will take anticoagulation 3.Accept life style change Mechanical valve Valve repair Reida El Oakley et al Circulation 2008;117:253-256 CONCLUSION No ideal heart valve prosthesis until now ( ideal # valve for life ! ) Appropriate chosen > Desirable chosen Healthcare condition is one of the most important thing ... healthcare condition)  Hemodynamic  Income performance ( supra-annular valve) AGE  Longevity age (WEF 2016) VN : 75.6 ; Singapore : 82.6 ; Thailand : 74.4; Philippines : 68.3 ; China : 75.8 ; HongKong... end-stage renal disease patients: systematic review and meta- analysis Kevin Phan et al J Thorac Dis 2016; 8(5):769-777 )  If life expectancy > 5y : Mechanical > Bioprosthetic valve (Contemporary perioperative